My perspective on the diagnosis.
As I have had several patients seek my care from long distances for their piriformis syndrome, I was curious to look into what the internet had to say about surgical treatment for piriformis syndrome. From what I have seen, there is a lot of confusion regarding the diagnosis and treatment of piriformis syndrome. I am an Orthopedic Surgeon specializing in hip surgery, mainly hip arthroscopy and hip replacements. With fellowship training dedicated to the hip, I have a specific interest in treating all types of problems around the hip, and piriformis syndrome falls into this category. In other words, you cannot adequately treat hip pain with arthroscopy unless you are able to perform the correct surgery for the relevant pathologies. You don’t do a hip scope (intra-articular scope with labral repair) for piriformis syndrome. With some of my background and perspectives stated, I will attempt to state my views and thoughts on Piriformis syndrome.
The first of which is in the name. The term Piriformis Syndrome (PS) sparks controversy because the piriformis gets a lot of the blame that perhaps is not the blame. Numerous anatomic structures exist in the deep gluteal space. The term Deep Gluteal Syndrome (DGS) is a better term to describe buttock pain and sciatic nerve pain of non-spinal origin. This describes the anatomic space underneath the layer created by the gluteus maximus muscle. I use the term piriformis syndrome only to be able to relate to those who use this term. To me, it doesn’t matter what we call it, as long as the problem/pathology is dealt with.
Another reason for controversy lies in the diagnosis of DGS/PS. In my opinion, PS is a diagnosis of exclusion. The first thing that has to be ruled out in buttock pain is if it is from the spine.This means that the history and physical exam are consistent with a problem arising from the deep gluteal space, and imaging studies of the spine are negative. In ruling out the spine, MRI of the lumbar spine is critical as a first step. Second, epidural injections can be diagnostic, and in cases of spinal etiology, therapeutic. When the lumbar spine has been ruled out as the etiology of the pain, the DGS becomes higher on the list as the cause of pain.
Once the deep gluteal space has been determined as the etiology of pain, the next step is treatment.